Provider rates through the Affordable Care Act in Pittsburgh will go up by as much as 50 percent in 2017.

Credit Healthcare.gov

Prices for health care coverage on Affordable Care Act exchanges nationwide are going up 25 percent, but in Pennsylvania that number is more than 32 percent and for some in southwestern Pennsylvania the increase will be nearly 50 percent.

After Highmark and UPMC requested rate hikes for 2017, the Pennsylvania Insurance Department approved even bigger hikes in an effort to bring stability to the market.

In 2016, four insurers offered plans in the Pittsburgh ACA marketplace. But Aetna and United Healthcare decided to not participate in 2017 due to mounting losses, leaving just Highmark and UPMC. In order to keep those remaining providers – and potentially attract others in the future – the state’s insurance department raised rates to prevent high losses.

“Our initial strategy was to take a five-year plan to profitability,” said Jim Stults, senior director of sales and account management at UPMC. “But the Pennsylvania Insurance Department felt that they needed to stabilize the market quicker.”

On average, a returning UPMC customer buying coverage on the ACA exchange will see rates increase by 26 percent. For a Highmark customer, it's an increase of 47 percent.

Alexis Miller, senior vice president of individual and small group markets at Highmark, said the increase allows Highmark to participate in the exchange but said more changes are still needed.

“I think we all have work to do in order to figure out how to make this market more sustainable in the future and that is going to take some tweaking to the ACA laws," she said.

Among the “tweaks” suggested by Miller are changes in how users can move in and out of the system. She said Highmark is also working to better educate customers who have never used insurance as to how to best use primary care doctors and preventative care to keep down expenses.

For Stults, none of the upheaval comes as a surprise.

“We actually always felt that the pricing and the likelihood of making money on (an exchange) product was really not just there, especially in the early stages," Stults said. "That’s why we priced our product much higher than our competitors did in the very first year of the marketplace."

Individuals who had purchased Aetna and United Healthcare plans in 2016 will automatically be enrolled in a UPMC or Highmark plan that the government thinks most closely aligns with their current policy. It’s unclear how much of an increase those users will see. Those users will have the option to shop for their own coverage.

“In western PA, even with the rate increases for 2017, our premiums are still going to be well below the national average,” Miller said. “And what that tells you is that premiums in western Pennsylvania were too low at the onset of the ACA.”

Most mental and behavioral health patients first get help through their primary care doctor. In fact, more prescriptions for antidepressants drugs are written by primary care physicians than by mental health doctors.

If your primary care physician says you need a test or procedure, and he suggests a location to get it done, what do you do?

“There is data that shows that patients do what their doctor says,” said Mark Roberts, chair of the department of Health Policy and Management at the University of Pittsburgh Graduate School of Public Health. “When your doctor tells you, ‘I want you to see a cardiologist and I want you to see this cardiologist,’ that’s who you go see.”